Ricci Chapter 13 - Test Bank - 4th Edition || A+ Certified
Answers.
1. A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure
whether she is in true or false labor. Which statement by the client would lead the nurse to
suspect that the woman is experiencing false labor?
A. "I'm feeling contractions mostly in my back."
B. "My contractions are about 6 minutes apart and regular."
C. "The contractions slow down when I walk around."
D. "If I try to talk to my partner during a contraction, I can't." Correct Answer: C
Rationale: False labor is characterized by contractions that are irregular and weak, often slowing
down with walking or a position change. True labor contractions begin in the back and radiate
around toward the front of the abdomen. They are regular and become stronger over time; the
woman may find it extremely difficult if not impossible to have a conversation during a
contraction.
2. A client is in the third stage of labor. Which finding would alert the nurse that the placenta is
separating?
A. uterus becomes globular
B. fetal head at vaginal opening
C. umbilical cord shortens
D. mucous plug is expelled Correct Answer: A
Rationale: Placental separation is indicated by the uterus changing shape to globular and upward
rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening,
and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is
termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a
premonitory sign of labor.
3. When assessing cervical effacement of a client in labor, the nurse assesses which
characteristic?
A. extent of opening to its widest diameter
B. degree of thinning
C. passage of the mucous plug
D. fetal presenting part Correct Answer: B
Rationale: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to
the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody
show as a premonitory sign of labor. The fetal presenting part is determined by vaginal
examination and is commonly the head (cephalic), pelvis (breech), or shoulder.
4. A woman calls the health care facility stating that she is in labor. The nurse would urge the
client to come to the facility if the client reports which symptom?
A. increased energy level with alternating strong and weak contractions
B. moderately strong contractions every 4 minutes, lasting about 1 minute
C. contractions noted in the front of abdomen that stop when she walks
D. pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds Correct
Answer: B
, Rationale: Moderately strong regular contractions 60 seconds in duration indicate that the client
is probably in the active phase of the first stage of labor. Alternating strong and weak
contractions, contractions in the front of the abdomen that change with activity, and pink-tinged
secretions with irregular contractions suggest false labor.
5. A woman is in the first stage of labor. The nurse would encourage her to assume which
position to facilitate the progress of labor?
A. supine
B. lithotomy
C. upright
D. knee-chest Correct Answer: C
Rationale: The use of any upright position helps to reduce the length of labor. Research shows
that women who assumed the upright position during the first stage of labor experienced
significant improvement in the progress of labor, faster fetal head descent, significant reduction
of pain, and a good Apgar score. Additionally, studies show that recumbent positions result in
supine hypotension, diminishing uterine activity and reducing the dimensions of the pelvic
outlet. The knee-chest position would assist in rotating the fetus in a posterior position.
6. A client has not received any medication during her labor. She is having frequent contractions
about every 1 to 2 minutes and has become irritable with her coach and no longer will allow the
nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The
nurse interprets these findings as indicating:
A. latent phase of the first stage of labor.
B. perineal phase of the first stage of labor.
C. late active phase of the first stage of labor.
D. early phase of the third stage of labor. Correct Answer: C
Rationale: Late in the active phase of labor, contractions become more frequent (every 2 to 5
minutes) and increase in duration (45 to 60 seconds). The woman's discomfort intensifies
(moderate to strong by palpation). She becomes more intense and inwardly focused, absorbed in
the serious work of her labor. She limits interactions with those in the room. The latent phase is
characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and
effacement of 0% to 40%, and excitement and frequent talking by the mother. The pelvic phase
of the second stage of labor is characterized by complete cervical dilation and effacement, with
strong contractions every 2 to 3 minutes; the mother focuses on pushing. The perineal phase of
the second stage is the period of active pushing. The third stage, placental expulsion, starts after
the newborn is born and ends with the separation and birth of the placenta
7. The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the
client for which type of birth?
A. cesarean
B. vaginal
C. forceps-assisted
D. vacuum extraction Correct Answer: A
Rationale: The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a
cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.
Answers.
1. A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure
whether she is in true or false labor. Which statement by the client would lead the nurse to
suspect that the woman is experiencing false labor?
A. "I'm feeling contractions mostly in my back."
B. "My contractions are about 6 minutes apart and regular."
C. "The contractions slow down when I walk around."
D. "If I try to talk to my partner during a contraction, I can't." Correct Answer: C
Rationale: False labor is characterized by contractions that are irregular and weak, often slowing
down with walking or a position change. True labor contractions begin in the back and radiate
around toward the front of the abdomen. They are regular and become stronger over time; the
woman may find it extremely difficult if not impossible to have a conversation during a
contraction.
2. A client is in the third stage of labor. Which finding would alert the nurse that the placenta is
separating?
A. uterus becomes globular
B. fetal head at vaginal opening
C. umbilical cord shortens
D. mucous plug is expelled Correct Answer: A
Rationale: Placental separation is indicated by the uterus changing shape to globular and upward
rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening,
and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is
termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a
premonitory sign of labor.
3. When assessing cervical effacement of a client in labor, the nurse assesses which
characteristic?
A. extent of opening to its widest diameter
B. degree of thinning
C. passage of the mucous plug
D. fetal presenting part Correct Answer: B
Rationale: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to
the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody
show as a premonitory sign of labor. The fetal presenting part is determined by vaginal
examination and is commonly the head (cephalic), pelvis (breech), or shoulder.
4. A woman calls the health care facility stating that she is in labor. The nurse would urge the
client to come to the facility if the client reports which symptom?
A. increased energy level with alternating strong and weak contractions
B. moderately strong contractions every 4 minutes, lasting about 1 minute
C. contractions noted in the front of abdomen that stop when she walks
D. pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds Correct
Answer: B
, Rationale: Moderately strong regular contractions 60 seconds in duration indicate that the client
is probably in the active phase of the first stage of labor. Alternating strong and weak
contractions, contractions in the front of the abdomen that change with activity, and pink-tinged
secretions with irregular contractions suggest false labor.
5. A woman is in the first stage of labor. The nurse would encourage her to assume which
position to facilitate the progress of labor?
A. supine
B. lithotomy
C. upright
D. knee-chest Correct Answer: C
Rationale: The use of any upright position helps to reduce the length of labor. Research shows
that women who assumed the upright position during the first stage of labor experienced
significant improvement in the progress of labor, faster fetal head descent, significant reduction
of pain, and a good Apgar score. Additionally, studies show that recumbent positions result in
supine hypotension, diminishing uterine activity and reducing the dimensions of the pelvic
outlet. The knee-chest position would assist in rotating the fetus in a posterior position.
6. A client has not received any medication during her labor. She is having frequent contractions
about every 1 to 2 minutes and has become irritable with her coach and no longer will allow the
nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The
nurse interprets these findings as indicating:
A. latent phase of the first stage of labor.
B. perineal phase of the first stage of labor.
C. late active phase of the first stage of labor.
D. early phase of the third stage of labor. Correct Answer: C
Rationale: Late in the active phase of labor, contractions become more frequent (every 2 to 5
minutes) and increase in duration (45 to 60 seconds). The woman's discomfort intensifies
(moderate to strong by palpation). She becomes more intense and inwardly focused, absorbed in
the serious work of her labor. She limits interactions with those in the room. The latent phase is
characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and
effacement of 0% to 40%, and excitement and frequent talking by the mother. The pelvic phase
of the second stage of labor is characterized by complete cervical dilation and effacement, with
strong contractions every 2 to 3 minutes; the mother focuses on pushing. The perineal phase of
the second stage is the period of active pushing. The third stage, placental expulsion, starts after
the newborn is born and ends with the separation and birth of the placenta
7. The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the
client for which type of birth?
A. cesarean
B. vaginal
C. forceps-assisted
D. vacuum extraction Correct Answer: A
Rationale: The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a
cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.
